Vol 19 Issue 1 Flashcards
A 36-year-old woman with type 1 diabetes on insulin is seen as an emergency at 34 weeks of gestation with severe vomiting, polyuria and blurred vision. She is examined and found to be drowsy, hyperventilating, tachypnoeic and hypotensive. You suspect that she has diabetic ketoacidosis. What test value will help you confirm the diagnosis?
A - Bicarbonate level of less than 10 mmol/l B - Blood glucose of more than 11mmol/l C - Blood ketone of more than 2.0 mmol/l D - Blood pH of less than 7.4 E - Urinalysis that shows ketonuria
Blood glucose of more than 11mmol/l
When a pregnant diabetic presents with features highly suggestive of diabetic ketoacidosis (DKA) a series of investigations have to be performed to confirm the diagnosis. These include a blood glucose level of more than 11 mmol/l, a blood ketonuria of at least 3.0 mmol/l or urinary ketonuria of more than 2+ and a bicarbonate of less than 15 mmol/l or a pH of less than 7.3.
How long after correction of diabetic ketoacidosis would the fetal heart rate be expected to have been normalised?
A - As soon as the DKA has been corrected B - 30–60 minutes C - 1−2 hours D - 2−4 hours E - 4−8 hours
4−8 hours
Fetal heart rate may demonstrate acidosis which is often corrected by rehydration of the mother and correction of metabolic acidosis. Normalisation of the fetal heart rate after the correction of DKA may require 4-8 hours. Fetal biophysical profile and Doppler studies may also reflect fetal acidotic status.
A 58-year-old woman has been diagnosed with endometrial cancer following investigations that included histology on an endometrial biopsy. She had surgery and has come back for review two weeks after the surgery. What will be the most important factor in providing a guide to prognosis?
A - Depth of myometrial invasion B - Histological type of the malignancy C - Lymphovascular space invasion D - Stage of the disease E - Volume of the tumour
Lymphovascular space invasion
Surgical staging for endometrial cancer allows histological grading of the tumour as well; as assessment of the depth of myometrial invasion, and perhaps most importantly in the last decade we have recognised that lymphovascular space invasion is arguably the most important prognostic factor.
A 50-year-old woman who had surgical treatment for cervical cancer three years ago now presents with clinical features of relapsed disease. This has been confirmed. What investigation will help determine whether she will have a chance of local control and cure from chemoradiation?
A - Computed tomography scan B - Examination under anaesthesia C - Magnetic resonance imaging D - Positron emission tomography E - Ultrasound of the pelvis and abdomen
Positron emission tomography
When patients relapse after primary surgical management, chemoradiation offers a chance for local control and cure if there is no evidence of distant metastatic disease. Positron emission tomography (PET)/computed tomography (CT) scanning will help identify patients with metastatic disease who are not suitable for radical treatments, but salvage levels may be quite high in carefully selected patients. Magnetic resonance imaging is best for pre-surgery imaging while PET scans are better for recurrence.
A woman who has had treatment for a gynaecological cancer is admitted with bowel obstruction. What type of gynaecological cancer is most associated with bowel obstruction?
A - Cervical cancer post radiotherapy B - Endometrial cancer post radiotherapy C - Epithelial ovarian cancer D - Germ cell ovarian cancer E - Stroma ovarian cancer
Epithelial ovarian cancer
Bowel obstruction associated with gynaecological cancer typically presents in those with recurrent disease. The most common cancer associated with bowel obstruction is epithelial ovarian cancer.
A woman who had treatment for ovarian cancer a few years ago presents with symptoms of bowel obstruction. Which symptom will make you suspect that the obstruction is in the proximal intestines?
A - Absolute constipation
B - Intermittent diarrhoea alternating with constipation
C - Nausea and vomiting
D - Spasmodic pain and vomiting
E - Spurious diarrhoea and then obstruction
Nausea and vomiting
Nausea and vomiting as the dominant symptoms may indicate proximal intestinal obstruction and may not be associated with marked abdominal distension; abdominal pain (often spasmodic) and distension are suggestive of distal obstruction. Absolute constipation is a classic feature of total obstruction, whereas watery/loose stools are often typical of partial or intermittent obstruction. Spurious diarrhoea can lead to a delayed diagnosis, as bowel evacuation is not initially considered consistent with an obstruction.
What is the main difference between an obese and a non-obese woman undergoing IVF/ICSI with respect to live birth rates after their first ART cycle?
A - Women with a BMI of > 30 kg/M2 have up to 20% lower risk of having a live birth compared to those with BMI< 30 kg/M2
B - Women with a BMI of > 30kg/M2 have up to 30% lower risk of having a live birth compared to those with BMI< 30kg/M2
C - Women with a BMI of > 30kg/M2 have up to 50% lower risk of having a live birth compared to those with BMI< 30kg/M2
D - Women with a BMI of > 30kg/M2 have up to 60% lower risk of having a live birth compared to those with BMI< 30kg/M2
E - Women with a BMI of > 30kg/M2 have up to 70% lower risk of having a live birth compared to those with BMI< 30kg/M2
Women with a BMI of > 30kg/M2 have up to 70% lower risk of having a live birth compared to those with BMI< 30kg/M2
Based on a comprehensive analysis of 4609 women undergoing IVF/ICSI stratified according to BMI category, it has been concluded that women with BMI of >30 kg/M2 have up to 68% lower risk of having a live birth following the first ART compared with women with a BMI of <30 kg/M.
What would be the recommended duration of physical activity for a 30 year old obese (body mass index of 33 kg/M2) woman who is trying to conceive?
A - Moderate intensity for at least 30−40 minutes on three or more occasions each week
B - Moderate intensity for at least 30−40 minutes on four or more occasions each week
C - Moderate intensity for at least 30−40 minutes on five or more occasions each week
D - Moderate intensity for at least 60−90 minutes daily four or more occasions each week
E - Moderate intensity for at least 60−90 minutes on five or more occasions each week
Moderate intensity for at least 60−90 minutes on five or more occasions each week
Physical activity should be of moderate intensity for at least 60-90 minutes on five or more occasions each week. Furthermore, activities should be of a type that can be incorporated into the daily routine, such as brisk walking, cycling, gardening or supervised exercise programmes.
A 45-year-old woman with heavy menstrual bleeding has been referred for secondary care. She is examined and the uterus is found to be equivalent to about the size of a 10 weeks of pregnancy. An ultrasound scan suggests the presence of small intramural fibroids. What surgical treatment option should be recommended for this woman, who has completed her family?
A - Endometrial ablation B - Myomectomy – open C - Myomectomy – laparoscopic D - Sub-total abdominal hysterectomy E -Total abdominal hysterectomy F -Uterine artery embolisation
Endometrial ablation
NICE recommends that in women with heavy menstrual bleeding (HMB) alone who have completed their family and have no desire for future fertility and who have a uterus no larger than it would be at 10 weeks of pregnancy, endometrial ablation should be the preferred surgical option to hysterectomy.
It has been estimated that the risk of having a hysterectomy for persistent menstrual symptoms is of the order of 14−20% following endometrial ablation. When after surgery is the risk of hysterectomy greatest?
A - Between 6 and 12 months B - Between the 2nd and 3rd years C - Between the 4th and 5th years D - In the first 6 months E - In the first 2 years
In the first 2 years
Rates of re-operation for recurrent menstrual symptoms following endometrial ablation are at least 20% and up to 27%; while between 14% and 20% of women will have a hysterectomy by five years, the majority of these will occur within in the first two years.
A 37-year-old primigravida is admitted in established labour at 29+4 weeks of gestation. She has been prescribed magnesium sulphate for neuroprotection. What is the correct dose to be administered?
A - A single 4g IV over 30 minutes and then a 1g infusion per hour until she delivers
B - A single 1g IV bolus over 30 minutes
C - A single 6g IV bolus over 30 minutes
D - A 4g IV bolus over 30 minutes every day until 30 weeks of gestation
E - A 1g IV bolus over 30 minutes every day until 30 weeks of gestation
Most trials on MgSO4 have used the existing pre-eclampsia regimen consisting of a bolus dose of 4g given intravenously over 30 minutes followed by 1g/hour until birth or up to a maximum of 24 hours. The infusion should be discontinued once the baby is delivered.
A diagnosis of a caesarean scar pregnancy has been made in a 23-year-old woman who had an elective caesarean section for breech presentation last year. She has been counselled and elects to have methotrexate. What baseline investigations should be performed prior to administering this systemic treatment?
A - Full blood count
B - Full blood count and liver function test
C - Full blood count, liver, lung and renal function tests
D - Full blood count, renal and liver function tests
E - Lung, liver and renal function test
Full blood count, renal and liver function tests
Methotrexate is the drug of choice for the medical treatment of caesarean scar pregnancy. Systemic administration of methotrexate is commonly used alone to successfully resolve human chorionic gonadotropin levels and caesarean scar pregnancy mass. Prior to its administration, all women should have a baseline full blood count, liver function and renal function tests.
A 30-year-old woman has been referred for an early ultrasound scan and booking for antenatal care on account or a past history that was complicated by an emergency CS that resulted in massive haemorrhage and blood transfusion. She is 7 weeks’ pregnant by her last menstrual period. An ultrasound scan is performed and this is suggestive of a caesarean scar pregnancy. Assuming that this diagnosis is correct what would be the most appropriate initial treatment approach for this patient?
A - Combined systemic and local methotrexate
B - Hysteroscopic resection
C - Local injection with embryocides such as methotrexate
D - Systemic methotrexate
E - Uterine artery emboliszation
Systemic methotrexate
Expectant management is generally not recommended except in very rare situations of CSP. The treatment of choice in those who are medically stable is methotrexate and this works best in pregnancies less than 8 weeks. Surgical management should be considered in women with significant symptoms and for those who decline medical treatment.
